What is the treatment for COVID-19 pneumonia?

Treatment for COVID-19 Pneumonia

The cornerstone of COVID-19 pneumonia treatment is effective oxygen therapy, starting with nasal cannula and escalating as needed to high-flow nasal oxygen, non-invasive ventilation, or invasive mechanical ventilation, along with remdesivir as the primary antiviral agent. 1, 2

Initial Assessment and Hospitalization

• Patients with COVID-19 pneumonia should be treated in designated hospitals with effective isolation protocols
• Suspected cases require single-room isolation; confirmed cases can be cohorted in the same ward
• Critical cases should be admitted to ICU as soon as possible 1
• Monitor vital signs continuously: heart rate, oxygen saturation, respiratory rate, blood pressure
• Regular laboratory monitoring:
  • Complete blood count, CRP, PCT
  • Liver and kidney function tests
  • Coagulation profile (prothrombin time before starting remdesivir)
  • Arterial blood gas analysis
  • Serial chest imaging 3, 1

Oxygen Therapy and Respiratory Support

• Begin supplemental oxygen when SpO2 is persistently below 94% 4

• Target SpO2 of 88-95% 4

• Escalation pathway based on severity:

  1. Nasal cannula or mask oxygen
  2. High-flow nasal oxygen therapy (HFNO)
  3. Non-invasive ventilation (NIV)
  4. Invasive mechanical ventilation 1

• Important caveat: Hypoxemia alone should not trigger intubation as it is often well-tolerated in COVID-19 patients 5, 6

• Intubation indications: signs of respiratory distress, fatigue, risk of exhaustion 5, 4

• Consider awake prone positioning for patients with persistent hypoxemia 4

• For intubated patients with refractory hypoxemia (PaO2/FiO2 < 150 mmHg), use prone positioning for 12-16 hours 4

• Consider ECMO for patients with refractory hypoxemia not responding to protective lung ventilation 1

Pharmacological Management

Antiviral Therapy

• Remdesivir is the primary antiviral treatment:
  • Adults and pediatric patients ≥40 kg: 200 mg IV loading dose on day 1, followed by 100 mg IV daily
  • Treatment duration:
    • Hospitalized patients requiring mechanical ventilation/ECMO: 10 days
    • Hospitalized patients not requiring mechanical ventilation/ECMO: 5 days (can extend to 10 days if no clinical improvement)
    • Non-hospitalized high-risk patients: 3 days 2
  • Start as soon as possible after diagnosis 2
  • Monitor liver function and prothrombin time before and during treatment 2

Corticosteroids

• Methylprednisolone 40-80 mg/day (not exceeding 2 mg/kg/day) for patients with:
  • Rapid disease progression
  • Severe illness 1
• Use cautiously as systemic glucocorticoids remain controversial for ARDS 3, 1

Antibiotic Therapy

• Avoid inappropriate use of broad-spectrum antibiotics
• For suspected bacterial co-infection:
  • Mild cases: amoxicillin, azithromycin, or fluoroquinolones
  • Severe cases: empiric coverage of all possible pathogens with de-escalation once culture results are available 3, 1

Thromboembolism Prophylaxis

• Enhanced prophylaxis against thromboembolism is important, especially for:
  • Patients with obesity
  • Known thrombophilia
  • Intensive care treatment
  • Elevated D-dimers 7

Supportive Care

• Ensure sufficient energy intake
• Maintain water and electrolyte balance
• Monitor and maintain acid-base homeostasis 1
• For fever >38.5°C, consider antipyretics such as ibuprofen 3

Special Considerations

• Lung-protective ventilation is essential for intubated patients
• COVID-19 pneumonia may differ from typical ARDS; limiting PEEP levels may be important 5
• The mortality rate in invasively ventilated COVID-19 patients can exceed 50%, emphasizing the importance of appropriate respiratory management 5
• For many patients with COVID-19 respiratory failure, increased oxygen and NIV may be sufficient, but the need for intubation must be continuously assessed 6